international journal of physiotherapy and research, case report … · 2019-12-14 · int j...

Int J Physiother Res 2015;3(3):1032-36. ISSN 2321-1822 1032

Case Report

EFFECTIVENESS OF CRANIO-CERVICAL TRAINING OVERMYOFACIAL PAIN SYNDROME: A CASE STUDYJeyanthi. S *1, Narkeesh Arumugam 2.

*1 Assistant Professor, Amar Jyoti Institute of Physiotherapy, University of Delhi / Ph D ResearchScholar, Punjabi University, Patiala, Punjab, India.2 Professor, Punjabi University, Patiala, India.

Background and Purpose: Myofascial pain syndrome (MPS) is a syndrome presenting with acute or chronicregional pain originating from trigger points (TPs) localized in the muscles or the fascia. TPs are local pointsshowing high irritability, sensitivity to finger pressure and causing characteristic referred pain. The aim of thiscase study is to assess the effectiveness of cranio-cervical training on neck disability, endurance of deepcervical muscles and pressure pain threshold in a patient with cervical myofascial pain syndrome.Case description: A 36 year old female who was diagnosed with myofascial pain syndrome. She received craniocervical training, a low load endurance exercises in order to train and/or to regain muscle control of thecervicoscapular and craniocervical regions. The patient received the treatment program for 10 to 15 minutes.The frequency of treatment is five days in a week for a period of 3 weeks.Outcome: The outcome measures were neck disability index, pressure pain threshold and deep cervicalendurance test, which were measured prior to treatment and at the end of third week.Conclusion: The craniocervical training programme for a patient with myofascial pain syndrome found to beeffective in reducing neck disability, improving the pressure pain threshold and deep cervical flexor muscleendurance.KEY WORDS: Myofascial Pain Syndrome, Cranio Cervical Training, Neck disability Index, Pressure Pain threshold,Deep Cervical Endurance Test.

ABSTRACT

INTRODUCTION

Address for correspondence: Dr. Jeyanthi. S (PT)., No.133 First floor, Ram Vihar, Karkardooma,Delhi -110092, India. E-Mail: [email protected]

International Journal of Physiotherapy and Research,Int J Physiother Res 2015, Vol 3(3):1032-36. ISSN 2321-1822

DOI: http://dx.doi.org/10.16965/ijpr.2015.129

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International Journal of Physiotherapy and ResearchISSN 2321- 1822

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DOI: 10.16965/ijpr.2015.129

Received: 28-03-2015Peer Review: 28-03-2015Revised: 16-04-2015

Accepted: 27-04-2015Published (O): 11-06-2015Published (P): 11-06-2015

Myofascial pain syndrome is one of the commonmusculoskeletal pain disorders which affectsalmost 95% of people with chronic pain disordersand is a common finding in specially painmanagement centre [1,2,3]. It is a syndromepresenting with acute or chronic regional painoriginating from trigger points (TPs) localized inthe muscles or the fascia. [2,4,5,6,7,8] TPs arelocal points showing high irritability, sensitivity

to finger pressure and causing characteristicreferred pain. Autonomic phenomena, fatigue,anxiety and depression often accompany thissyndrome [2,4].Although, the etiology of TPs development iscurrently unknown, the studies havehypothesized that the pathogenesis results fromthe overloading and injury of muscle tissue,leading to involuntary shortening of localizedfibers [9,10]. Myofascial pain syndrome alsooccurs due to poor posture, overuse, acute

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Jeyanthi. S, Narkeesh Arumugam. EFFECTIVENESS OF CRANIO-CERVICAL TRAINING OVER MYOFACIAL PAIN SYNDROME: A CASE STUDY.

trauma, vitamin deficiency and psychologicalstress [9]. The authors have found that thetrapezius is probably the muscle most oftenbeset by myofascial trigger point. It is afrequently overlooked as the source of temporal& cervicogenic headache. The upper trapeziustrigger point consistently refers pain along withthe postero lateral aspect of neck to mastoidprocess and was the major source of tensionneck ache. When pain is referred frommyofascial trigger point in other muscles suchas sternocleidomastoid, suboccipital andtemporalis, it overlaps to result in tensionheadache [2]. Further, literature hasdemonstrated that patients with myofascialpain had significantly less strength andendurance of the deep neck flexors comparedto age-matched control [11]. A muscle withtrigger points may not fully lengthen or shortenand for that reason it will have diminishedmuscle strength and endurance and will fatigueeasily [12].Numerous treatment options targeting at thetrigger points are available such as LASER, triggerpoint injection, spray and stretch method, dryneedling, ultrasound, TENS, trigger pointpressure release (TrPPR)/ischemic compression(direct inhibitory pressure), muscle energytechnique (MET), myofascial release therapy(MRT), positional release therapy (PRT) i.e.strain counter strain technique and integratedneuromuscular inhibitory technique(INIT)[13,14]. In addition it has been found theefficacy of Upper cervical flexor strengtheningin reducing pain & disability in upper trapeziustrigger point patients [15]. The purpose of Uppercervical flexor strengthening is to increasemuscle strength/ power, therefore the exercisesare performed with high load, less repetition,whereas craniocervical training is performedwith low load for prolonged period of time.However, no previous trial has investigated theeffect of craniocervical training in myofascialpain syndrome. Cranio-cervical training is asimple & easy way to increase endurance ofdeep cervical flexors.Thus, the aim of present case study is to assessthe effectiveness of cranio-cervical training (alow load training program for deep cervicalflexors) on neck disability, endurance of deep

cervical muscles and pressure pain threshold ina patient with cervical myofascial painsyndrome.

Case Description:

Patient history and System review: A 36-year-old, right handed female presented withcomplaints of posterior and lateral neck pain.She described pain symptoms as continuous,which aggravates while doing clerical work inher office. There was no previous history of suchsymptoms, nor any other muscular or skeletalconditions. The patient appeared to be withinhealthy weight parameters, and hadexperienced no recent, unusual weight gain orloss. She had no history of trauma or blunt forceimpact that could be linked with the onset ofsymptoms.The patient stated that her symptoms beganmore than a month ago, during a time when shespent long periods of desk job at her office. Shereported that her symptoms had been graduallyworsened during the course of the previous onemonth. The patient initially consulted her familyphysician in order to rule out possiblepathological or systemic causes. A series ofblood and urine tests were performed whichreportedly all proved to be within normal limits.The physician diagnosed the problem asmyofascial pain syndrome and she was thenreferred to a Physiotherapist. Since then she wastaking treatment at physiotherapy OPD, PunjabiUniversity. A informed consent was taken fromthe patient and the case study was performed.Examination: Postural evaluation demonstratedforward head posture, bilateral protracted androunded shoulders. Cervical ranges of motionindicated reduced flexion, with right and leftrotation decreased by 20% and lateral flexionreduced by 20%. The manual muscle testing ofdeep cervical flexor muscles was found to befair. [16] Further reduced flexibility in bilateralpectoralis major & minor and in suboccipitalmuscles was evident. Neurological evaluationof both upper and lower extremities wasunremarkable i.e., Deep tendon reflexes were2+ (symmetric) and sensory response (pin prick& gentle touch) was normal.Evaluation of the cervical spine revealedmoderate myofascial pain in the para-vertebral



musculature. Deep tissue palpation of the uppertrapezius muscle bilaterally indicated presenceof multiple trigger points, which referred painto the sub-occipital area when provoked.Palpation of the suboccipital, bilateral levatorscapular muscles also indicated the presenceof myofascial trigger points. Passive accessoryspinal motion was checked by applying centralpostero-anterior pressure and lateral postero-anterior pressure on all the cervical spinesprocesses and facet joints respectively and jointplay was found to be reduced. This clinicalexamination also reconfirmed the physiciandiagnosis.Further examination included assessment ofneck pain and disability using Neck DisabilityIndex (NDI) score. The NDI questionnaireconsisted 10 sections, (each section grades from0 to 5) with questions pertaining to feedback ofthe subjects regarding their pain, ability to doactivities of daily living, ability to concentrateand presence of headaches. The scale consistedof discrete categories within which each itemwas weighted and responses were summed up,divided by total score which is 50 and itspercentage was taken. NDI had a high degreeof reliability and internal consistency [17].The cervical flexor muscle endurance wasassessed with the patient is in crook lyingposition and hands resting on the abdomen.Patient was instructed to maximally tuck in thechin and maintain the position isometrically,leading to lifting of the head and neckapproximately 2.5 cm from resting position.While in this position a line was drawn across 2approximated skin folds along the anterolateralneck. The time between assuming the testposition until the chin begins to thrust or theedges of the drawn lines across the skin foldsno longer approximate each other (because ofloss of chin tuck) was measured in seconds witha stopwatch [18]. Three consecutive measure-ment at an interval of 30 seconds were takenand average was obtained. The test used is avalid and reliable measure of deep neck flexorendurance [19,20].For measuring Pressure Pain Threshold (PPT), amechanical pressure algometer was used[21,22]. This device consists of a round rubberdisk (area, 1 cm2) attached to a pressure (force)

gauge. The gauge displays values in kilograms.Because the surface of the rubber tip is 1 cm2,the readings are expressed in kilograms persquare centimeter. Average value was obtainedfollowing three consecutive measurements ofPPT levels on the upper trapezius (as shown inFigure 1), Sub occipital and Levator scapulaemuscles Tps, each at interval of 30 seconds.

Fig. 1: Pressure Pain Threshold Measurement UsingPressure Algometer Over Upper Tapezius Trigger Point.

Treatment: The Craniocervical TrainingProgramme (CTP) was a new developedprogramme using low-load endurance exercisesin order to train and/or to regain muscle controlof the cervicoscapular and craniocervicalregions [23]. To address the impairment in neckflexor synergy found in cervicogenic headacheand other neck pain disorders [24,25],craniocervical flexion exercises were performed,using a latex band (Thera-Band®, ResistiveExercise Systems; blue colour-coded level ofprogressive resistance). The 150-cm latex bandwas used as a circular band, with one sidepositioned at the craniocervical region of thepatient’s neck and the other side fixed somewhatabove the horizontal. The resistance of the bandwas used in such a way that it facilitated thelongus colli muscles [26]. Exercises wereperformed in a sitting position with a naturallumbar lordosis, with slight scapular retraction& adduction and by slightly elongating thecervical spine as shown in Figure 2 and 3. Twosets of 12 repetitions each were performed (20seconds hold time and 10 seconds rest time).Rest period between each set was 30 secondsand CTP part of treatment session lasts for 15minutes. The patient was advised to perform theexercises twice at home. Hot pack was appliedat the neck for 15 minutes. In addition to theCTP, information regarding postural awarenessand ergonomic advices for home and at



workplace were also provided.Fig. 2: Craniocervical Training Starting Position.

Fig. 3: Craniocervical Training End Position.

Outcomes:

The patient was treated for a period of threeweeks (5 sessions/ week). The patient’s pretreatment Neck Disability Index score was 60%suggesting moderate disabilty whereas posttreatment disability score was reduced to 20%which showed slight disability. Further deep neckflexor endurance test time was increased from14 seconds to 24 seconds following thetreatment regimen. Pressure pain threshold forupper trapezius, sub occipital and levatorscapulae muscles was 0.90, 1.10, 0.80 Kg/cm2

respectively before starting the treatmentwhereas it was increased to 1.32, 1.24, 1.14 Kg/cm2 respectively after giving treatment. Thepatient also showed 200 increases in cervicallateral flexion, increased flexibility in uppertrapezius and levator scapulae muscle.Improvement in joint play and posture was alsoevident.

DISCUSSION

exercise, mobilisation effect is produced atupper cervical spine which modulates the painperception which further reduces pain.[27,28,29,30,31,32] Furthermore, specificcraniocervical training program emphasizedmotor control rather, than muscle strength. [33]Reduced deep cervical flexor endurance resultsin increased fatigability of muscles, which in turnaffects the concentration and the ability to workand its long term effects eventually leading toincreased cervical lordosis or forward headposture. Thereby, neck endurance training notonly reduces pain but also improves thepatient’s ability to perform personnel care,reading, driving, having sound sleep, engagingin recreational activities and improving faultyposture.Thus short term results of cranio cervical trainingin this particular case was found to be favorable,although long term outcomes were not observed.Further research focusing on evaluation of longterm outcomes of Cranio-cervical TrainingProgram in patients with Myofascial PainSyndrome should be executed. A RandomizedControlled Trial can also be conducted togeneralize the effectiveness of this treatment.

This trial supported that the use of Craniocervical Training Programme for patient withMyofascial Pain Syndrome has not onlyeffectively improved deep cervical musclesendurance and pressure pain threshold but alsoreduced neck disability. This is attributed to thefact that while performing craniocervical

CONCLUSION

The Craniocervical Training Program was simpleand easy to understand and found to be effec-tive in reducing symptoms associated withmyofascial pain syndrome as well as improvingdeep cervical flexor muscle endurance.

Conflicts of interest: None

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How to cite this article: Jeyanthi. S, Narkeesh Arumugam. EFFECTIVENESS OFCRANIO-CERVICAL TRAINING OVER MYOFACIAL PAIN SYNDROME: A CASE STUDY.Int J Physiother Res 2015;3(3):1032-1036. DOI: 10.16965/ijpr.2015.129

international journal of physiotherapy and research, case report … · 2019-12-14 · int j...

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